Family doctor services registration (GMS1)

Provide the details below to register with the Practice.
A member of staff may need to telephone you to confirm certain aspects of your Registration.

Please select the practice location most relevant to this Online Form submission:

Patient’s details

Title

First Names

Surname

Previous Surname/s

Gender

Date of BirthDD/MM/YYYY

Town and Country of birth

NHS Number (if known)If you know your NHS Number, please provide it

Home Address

Postcode

Telephone Number

E-mail Address

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident of UK, date of leaving

Date you first came to live in UK

If you are returning from the Armed Forces

Address Before Enlisting

Service or Personnel Number

Enlistment Date

If you are registering a child under 5

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist.

I would have serious difficulty in getting them from a chemist.

Not all doctors are authorised to dispense medicines

NHS Organ Donation registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.

For more information, please ask at reception for an information leaflet or visit the website
www.uktransplant.org.uk, or call 0300 123 23 23.

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to give blood.

I have given blood in the last 3 years

My preferred address for donation is different from above, e.g. my place of work

For more information, please ask for the leaflet on joining the NHS Blood Donor Register.

For all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the
GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the
time being. In most cases, nationals of countries outside the European Economic Area must also have the status of
‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are
free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the
Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice,
otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any
immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be
shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation,
invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

I am not ordinarily resident in the UK

A parent/guardian should complete the form on behalf of a child under 16.

Complete this section if you live in another EEA country, or have moved to the UK to study or retire,
or if you live in the UK but work in another EEA member state. Do not complete this section if you have
an EHIC issued by the UK.

I have a non-UK EHIC or PRC

I have an S1 Form (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state.)

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP
appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost
recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of
recovering your NHS costs from your home country.

Confirm

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toFarley Road
•
53 Farley Road, South Croydon, Surrey, CR2 7NG.

Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.